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  1. I understand that the First Health Network hospitals that I am about to access are covered for emergency services and urgent care services only and apply only when I am traveling 100 miles or more from my worksite. If you do not understand (Call ACTIN at 877-602-1288).
  2. I understand that the First Health Network Urgent Care facilities that I am about to access are NOT covered in the following Illinois counties—Adams, Boone, Cook, DeKalb, DuPage, Kankakee, Kendall, Winnebago, and Will Counties. I understand that in those counties Physicians Immediate Care Urgent Care facilities are the only Urgent Care Centers covered by my Plan. If you do not understand (Call ACTIN at 877-602-1288).
  3. I understand that I must contact ACTIN to determine other non-emergency services covered by my Plan through the First Health Network. If you do not understand (Call ACTIN at 877-602-1288).
  4. I understand that St. Alexius Medical Center, 1555 Barrington Rd, Hoffman Estates, IL 60169, Alexian Brothers Medical Center, 800 Biesterfield Road, Elk Grove Village, IL 60007, Presence St. Joseph, 77 N Airlite St, Elgin, IL 60123, and Loyola University Medical Center. 2160 S 1st Ave, Maywood, IL 60153 are the only hospitals in network for emergencies within a 100-mile radius of my worksite.
  5. I understand that the plan will pay at least its median rate for contracted hospitals if I am admitted as an emergency to out of network hospitals but that I could be billed for the difference in what the hospital charges and the Plan pays.
  6. I understand that it is my best interest to contact the Plan as soon as possible after I am admitted to an out of network hospital in an emergency in order to reduce the chance that I could owe the difference in what the hospital charges and the plan pays.